management of pregnant patients

1. MANAGEMENT OF PREGNANT PATIENTS IN
ORAL SURGERY
SUBMITTED BY
MANJARI RESHIKESH
III BDS
DEPARTMENT OF ORAL AND MAXILLOFACIAL
SURGERY

2. Pregnancy has been considered as
an impediment to dental
treatment,
 preventive, emergency and routine
dental procedures - suitable during
various phases of pregnancy, with
some modifications and initial
planning

3. STAGES OF PREGNANCY
FIRST TRIMESTER(0-12WKS)
SECOND TRIMESTER(13-28WKS)
THIRD TRIMESTER(29-40WKS)

4. MATERNAL CONCERS
ANATOMIC CHANGES
PHYSIOLOGICAL CHANGES
PSYCHOLOGIC CHANGES

5. ANATOMIC CHANGES
 WEIGHT : Uterus weight from 70gm  1 kg
►VOLUME : Uterus volume from 10ml 5000 ml
 SIZE: size increases
 SHAPE: Pyriform to globular

6. PHYSIOLOGIC CHANGES
Cardiovascular system
Respiratory system
Gastrointestinal system
Renal system
Hematological system
Endocrine system

7. CARDIOVASCULAR SYSTEM
 Cardiac output increase 30% in first trimester.
Then
 BP normal in 1st and in 2nd trimester
 2nd trimester heart rate increases 10 beats/min
 3-4% - pre eclampsia and eclampsia
(hypertensive disorder of pregnancy)

8. GASTROINTESTINAL TRACT
 Morning sickness-Nausea, vomiting and
giddiness
 Increase gastric acid production
 Indigestion and hypo chlorhydria occur
 Decrease gastric mobility&constipation

9. RESPIRATORY SYSTEM
►Overall activity increases
 Diaphragm is displaced
upward3~4cm&residual volume decrease
 rib flare out with wide chest
►Oxygen consumption increase 15~20 %
►Respiratory rate increases

10. RENAL SYSTEM
 Increased GFR and urine(diluted)
 In first trimester frequency of urination
increases –pressure exerted by bladder
 Urinary tract infection common

11. HEMATOLOGICAL CHANGES
 Total blood volume increase
40~50% (1500ml)
 Hemoglobin & hematocrit
volume decrease
 Plasma levels of factors VII, VIII,
X and fibrinogen increase
 Fibrinolytic activity decrease

12. ENDOCRINE CHANGES
Estrogen & progesterone increased. LH &FSH decrease
Thyroxin, steroid and insulin level are also increased.
HPL causes increase size of breasts
45 % -fail to produce sufficient amount of insulin &
develop gestational diabetes.

13. PSYCHOLOGICAL CHANGES
FIRST TRIMESTER
 Anxiety
 Sudden emotional
swings
 Fear of abortions
SECOND TRIMESTER
 Self conscious about
weight &Appearance
 Regarding movemnts of
baby
THIRD TRIMESTER
• Anxiety about labor
and baby

14. POSITIONING OF PATIENT IN EACH
TRIMESTERS
 LATTER PART OF 1st trimester-semi reclining
 SECOND TRIMESTER-Semi Reclining position
 THIRD TRIMESTER-LEFT LATERAL DECUBITUS POSITION(30° left
lateral tilt) to prevent supine hypotensive syndrome

15. SUPINE HYPOTENSION SYNDROME
 Third trimester 10-15%
 Compression of inferior vena cava & aorta
 Decrease venous return to heart
 Decrease utero placental perfusion and
fetal distress

16. LEFT LATERAL DECUBITUS POSITION
 Elevate the right hip 10-12cm by
keeping a small pillow –Left lateral
displacement
 Sit up position

17. FOETAL CONCERNS
Ovum- from fertilization to implantation period (0-17 days)
Embryonic period- from the second through eighth week
Fetal period- after the eighth week until term

18. OVUM PERIOD
►Conception to 17 days
►Cellular mitotic activity
►toxic substances - spontaneous
abortion

19. EMBRYO PERIOD
 18-55 days (2nd~8th wk)
 Organogenesis
 Most vulnerable to teratogens
 Functional & morphologic malformation may
occur

20. FETAL PERIOD
• 56 days onwards
• Growth & development

21. FIRST TRIMESTER(1-12 weeks)
 Stage of organogenesis when all the major organs
are laid down and starts functioning.
 50% of abortions
 MOST SUSCEPTIBLE TO ADV EFFECTS OF
TERATOGENS
 AVOID ALL ELECTIVE CARE BUT PROVIDE CARE AS
NEEDED
 AVOID X RAYS
 Tooth extraction-Latter part of 1st trimester

22. SECOND TRIMESTER(13-28weekS)
• Organogenesis complete
• Fetal growth and maturation
• Gains weight rapidly
• SAFEST PERIOD TO PROVIDE DENTAL CARE

23. THIRD TRIMESTER(29-40weeks)
• Fetus fully developed and ready for delivery
• Dental treatments are contraindicated
• Premature labor or abortion
• Extraction- First month of last trimester

24. RADIOGRAPHY
 Dose given & time of gestation
 Fetus - susceptible to radiation during
first trimester(2nd -6th wks)
 Single dental x ray - 0.01 milli rads
HAZARDS OF IRRADIATION
• Death of embryo
• Birth of deformed child
• Increased frequency of malignancy.eg.Leukemia

25. PREVENTION OF IRRADIATION
HAZARD
 Make the film if it is absolutely essential for
diagnosis(RCT,Trauma)
 Use lead-shielding
 Use long cone, proper collimation & shielding
 Limited to affected tooth
 Extra care taken while making films to eliminate
the need for repeated exposure

26. MEDICATIONS
†Local anesthesia
†Antibiotics
†Analgesics
†Corticosteroids
†Sedatives

27. MEDICATIONS &GENERAL EFFECTS OF
DRUGS IN PREGNANCY
FIRST TRIMESTER:
Congenital malformations(teratogenesis)
SECOND TRIMESTER:
Affect growth & Fetal development or toxic
effects on fetal tissues
THIRD TRIMESTER:
Adverse effects on labour or neonate after
delivery

28. DRUG CATEGORIES

29.  Some of the X category drugs are:
1. Ribavirin
2. -Accutane(isoretinoine)
3. Thalidomide - phocomelia
4. Sodium valproate
5. Phenytoin
6. Phenobarbitone
7. Methotrexate
8. Warfarin(Fetal warfarin syndrome)

31. LOCAL ANESTHESIA
• Not teratogenic
• used in pregnancy with no proven ill
effects
• intravascular injections -the concn - too
low to harm fetus
• Prilocaine may cause methemoglobinemia

32. LOCAL ANAESTHETICS USED IN PREGNANCY
CLASS B
• Lidocaine
• Etidocaine
• Prilocaine
CLASS C
• Procaine
• Bupivacaine
• Mepivacaine

34. ANTIBIOTICS USED IN PREGNANCY
 PENICILLIN
FDAB
 safe- all trimesters
 No teratogenic effects
 Pass the placenta
 CEPHALOSPORIN
 Cephalexin-FDA B
 Erythromycin(BASE) FDA-B

35. ANTIBIOTICS TO AVOID DURING
PREGNANCY • Erythromycin (estolate form)
• Vancomycin
• Tetracycline(D)-tendonitis ,tendon rupture
• Chloramphenicol(C) –greybaby synd, BD,
• Aminoglycosides(D)-oto-toxicity,
nephrotoxicity
• Trimethoprim-decreased folicacd synthesis

36. MNEMONICS

37. OTHER ANTIMICROBIAL AGENTS USED
IN PREGNANCY
• Nystatin (B)
• Chlorhexidine rinse (B)
• Clotrimazole (C)
• Ketoconazole (C)
• Fluconazole (C)

38. ANALGESICS
 Identify cause- avoid use
ANALGESICS USED IN PREGNANCY
1. Paracetamol (B)- safest
2. Acetaminophen(B)-safe

39. CONT…
 Ibuprofen( B/C) Avoid in 3rd trimester
 Cox-2 inhibitors (C) Avoid in 3rd trimester
 Codeine (C) Avoid in 3rd trimester
 Morphine (B)

 Fentanyl (B)

40. ANALGESICS TO AVOID DURING PREGNANCY
 NSAIDS
Aspirin- tetralogy of fallot
prolonged pregnancy and labor
increased risk of hemorrhage
Premature closure of DA
 Ibuprofen avoided in 3rd-circulatory problrms
 Codeine-3rd trimester-fetal withdrawal &Respirtory
depressn

41. CORTICOSTEROIDS
Not commonly used in pregnant
patients:
1. Inhibit brain growth
2. Cleft palate
 Indicated only for treating severe
systemic illness
 PREDNISOLONE(B)-used

42. SEDATIVES
Sedatives/anxiolytics are rated as FDA-D
Can cause oral clefts on prolonged exposure
 BARBITURATES
a) Cross the placental membrane
b) Chronic barbiturate use-withdrawal syndrome
c) Cleft palate-lip

43.  BENZODIAZEPINES(Diazepam)
1. Cleft lip and palate
2. Chronic diazepam user-tremors in infants
 INHALATIONAL SEDATVES
 Increase rate of spontanous abortion
 NO2 not be used in 1st trimester
 If used in 2nd and 3rd,do not go below 50%

44. OBSTETRIC EMERGENCIES IN DENTAL
OFFICE
SYNCOPE
MORNING SICKNESS
SEIZURES
BLEEDING AND CRAMPING

45. SYNCOPE
 All trimester
 causes-
1. Hypotension,
2. dehydration,
3. anemia,
4. hypoglycemia and
5. neurogenic disorder

46. Turned to left side
Administer O2 &maintain vital signs
Not revived with ammonia
Sugar containing fluids given

47. MORNING SICKNESS
Nausea & vomiting
• Avoid morning appointments
• Enhanced gag reflex
• Oropharygeal suction –prevent aspiration
• Chest compression- advanced stages of pregnancy
MANAGEMENT

48. SEIZURES
 Cause- Eclampsia
 Signs- generalized edema
 elevated BP (sys>140 & dia> 90),
 severe headaches, blurred vision, or
abdominal pain
 . Seizure with aspiration of gastric contents -
maternal death.
 Hypoxia - fetal death.

49. MANAGEMENT
IF seizure develop during dental treatment
administer oxygen by placing her on her left lateral position,
apply suction to the airway
provide emergency transport to a hospital.

50. BLEEDING AND CRAMPING
vaginal bleeding -sign of impending miscarriage.
MANAGEMENT
place on left side,
administer oxygen
transport to the nearest hospital

51. THANK YOU